14 Case of the Day - HIV and Drug Resistance

Doug Fink 03/09/18

How do WHO treat HIV? 2 NRTI plus third agent.

There are still people admitted to hospital, dying, who are on ART, who are failing ART.

If you fail a line of therapy, move on to the next line. ~14% in Tanzania are failing first line therapy.

30 yr female. Diagnosed HIV during complicated labour. Asymptomatic.

Started on TDF/FTC + NVP

6 months later started follow up. Travels 60km fr clinic, avoid

Weight loss, diarrhoea. Localised lesions on left foot, looking like Kaposis sarcoma.

So this was a clinical failure treatment. Labs showed immunological failure with falling CD4 count.

So she was switched to AZT/3TC + LPVr (2nd line)

A year later she represents. Her CD4 count is unchanged and has detectable viral load virological failure.

TDF/FTC + DRVr (“3rd line”)

Then lost to follow up. Next seen two years later as inpatient. There were problems with drug supply, hasn’t been taking ART, has been taking traditional meds.

What do you do now?

In the west resistance testing would be unequivically what you would do next, often not available in african settings. Her resistance showed her to be susceptible to NRTI and all PIs

Do not switch ART without adherence testing.

She should go back to her current regimin and enhanced adherence testing.

Detecting treatment failure is important as these people present to hospital, sick, and they die.

We use the WHO staging of clinical failure, but months or years before we see changes immunological failure, and months before that we see virological failure.

Virological Failure: VL at 6 months 2 VL detected 3 months apart

Immunological failure: Determined by CD4 count at 12 months

Clinical failure: Determined by WHO staging

People fail ART due to resistance, but the major issues are social factors (Drug supply, distance to treatments, Lack of counselling, family support, priorities of food/childcare)

70% failure of first line treatment is reversible with enhanced adherence

  • First line failure is common,
  • Second line failure is rare
  • VF doesnt automatically mean resistance
  • VL testing is a tool to identify those in need of adherence support
  • ART adherence and monitoring are challenging anywhere